Summer in Botswana

Thursday, September 8, 2011

The biggest gift I got in Botswana was the chance to work with an amazing group of people. This experience would have been nothing without them. I was blown away with their generosity in teaching me and I am hell-bent on “paying it forward” at every available opportunity.

Dr. Kovarik: she is the principle investigator of the vulvar cancer study and she is the one who sent my to Botswana. First of all, I am in awe of her: her accomplishments are staggering especially given how young she is. More than that, I am impressed by her can-do attitude: she is involved with so many projects and . I was introduced to her by a dermatologist I was shadowing and within our first meeting she set me up with this opportunity and even tried to help me find another project for last spring.

Her trust in me was really humbling and I was determined not to let her down. She was so supportive of my throughout this whole process: responding thoughtfully to my emails and encouraging me to pick up other projects. Also, I really appreciate that Dr. Kovarik was willing to let me shape my own experience. Not only that, she really listened to my input when I raised concerns or offered suggestions on how to better the study. I can't believe how lucky I was to have had this opportunity and I really hope I can work with her in the future.

Jennifer (aka Jenny G): although Jenny was only around for a week, I feel like I found a lifelong friend (yes, corny). Jenny gave me permission to unleash my inner derm nerd. She would answer streams of questions, let me do board exam practice questions with her and talk to me about how I can get more involved with derm at Penn. I can’t think of a more patient, non-pretentious and thoughtful teacher than Jenny. I am actually writing this post on a bus to NYC and one of the reasons I’m going (besides my birthday on Monday!) is to see Jenny who just took her first job there!

Aileen: Aileen is a fourth year at Penn and I've adopted her as my "derm big sister." We met before Bots and clicked right away. She offered me advice on everything from when to do my rotation to which necklace to wear and she was even nice enough to let me help her with a mobile learning study. I'm psyched that she's in Philly another year.

I've already written about Kari and Dougie so I'll keep in brief but no list of mentors would be complete without these two:

Kari (aka the Wanat aka Armageddon): Kari Wanat may be the nicest person ever but trust me, she is no pushover. Her arrival was a burst of enthusiasm and to say that she is hardworking and intelligent is an understatement. And her unique combo of disarming smile + midwestern accent + determination is amazingly effective at getting things done!

Doug (aka Dougie Fresh): my partner in crime for 4 weeks and one of the funniest people I have ever met. He was endlessly patient with me and my insane amount of questions and a great doctor.

As you can see, I was really blessed to have hung out with such an awesome crew. They shaped my experience in such a major way. I am but a lowly med student peon so I can't express enough gratitude for how much they included me and shared their knowledge and experience. So thanks to team derm for making this such an unforgettable summer!

P. S. Thanks so much to Jessica Mikulski and Penn for spotlighting my blog on the Penn Medicine website Renee Chenault-Fattah for interviewing me on NBC Healthwatch before I left/featuring my blog on their facebook page, and Lisa Katz for linking my blog on the PSOM alumni page. Lastly, thanks to my grandmother for reading this blog because despite all the above publicity, I'm pretty sure she's the only one to actually read most of it (confirmed by the fact that my own mother admitted to being a periodic reader...love you mom!).

P.P.S If you reallllllly miss my killer puns and witty prose (I'm looking at you Nana)....I'm blogging as a part of the Perelman School of Medicine blog. No meerkats or lions (yet....) but I've already posted a picture of me waist deep in the dirty water of the Schuylkill river so that might be worth a gander just to laugh at my poor judgment.

1. A love of dermatology: I learned so much in a very literal sense: while my Setswana didn’t improve as much as I might have liked, I learned so much of the language of dermatology. And I loved it. I can't wait to get more involved now that I'm back at school. I've been finding cardio tough so I've started a game with Kari where I email her the disease we are learning about and she replies with the skin problems that go along with that disease. Luckily Jen donated a large pile of derm books so I'll have plenty of opportunity to keep learning. I know, I know...I'm a huge nerd.

2. The knowledge that I want to make international work a part of my career. I felt so at home in Bots and I felt the same way in Malawi. I can't wait to find out how my career evolves to include this passion.

How could you not want to work somewhere this amazing?

3. Most importantly however, I learned, or rather got re-acquainted with, my own competence. Medical school isn’t kind to everyone and although I’ve been very successful grades-wise, I’ve been struggling with my own version of the imposter syndrome common to medical students: I keep waiting for someone to “find out” that I am not as smart or as hardworking as my classmates. And frankly, in some ways, that is true. I am not great at sustained periods of memorization and that is the key to med school success in many ways. I think that last year, I always felt sort of bad because I wasn’t spending as much time with the material as my classmates. As we learned in psychiatry, situations like that can set you up to create a very negative self-evaluation. Fears about not living up to my potential made it hard to be proud even though I did really well in terms of external markers like grades.

Botswana was the antidote to that feeling: I wanted to go to work...wanted to stay longer at work... wanted to find projects that would give me more work and I did that work well enough that people started giving me more and more responsibility. Positive feedback is always great but feeling proud of myself was the best feeling in the world. So basically, I had the opportunity to re-ignite my passion for medicine while meeting and working with some truly amazing people. I will echo my first post....am I lucky or what?

Ever since I’ve been back, I’ve been trying to synthesize my Botswana experience and decode what it meant to me, what I learned and how I wanted to grow as a result of my time there. Sheesh. Talk about biting off more than you can chew. This sort of experience, unsurprisingly, doesn’t take kindly to attempts to categorize, contain or label it in a consise way but as per usual, I’m going to try my best. Also per usual, I was feeling verbose and thus am going to split up my thoughts into 3 posts.

Patience, perseverance and the delicate combo thereof: my experience in Malawi gave me a leg up on this one: it can be so incredibly frustrating to work in a developing country. Most people think that is because of a lack of resources: “it must be hard to want to treat someone with a medicine or procedure that you don’t have.” I suppose that is true, but I think that most people who do this kind of work are prepared to make the best of what is available. What people are less prepared for is dealing with what people like to term “cultural differences” or “inefficiencies” (I find these somewhat euphemistic).

Hard to get frustrated when you get to see babies in clinic

I told Kari of the metaphor I like to use for my interactions at the hospital: one of the those dolls that you punch but they keep springing back up. Whenever I wanted to accomplish something (fix a microscope, check on a patient, get a photocopy, install software etc), I would get rebuffed or redirected almost instantly: “why don’t you talk to Mr. So and So, come back later, we don’t do that here etc etc.” I'd call it getting PMH-ed. The trick was not to get annoyed by that or respond by being pushy. I would simply write down the information I needed and say “What is Mr. So and So’s phone number? I will be here tomorrow at 8:00 and I hope to find him here.” Do this enough and people realize that you are serious and they will help you. Remarkably effective actually.

When all else fails, use junk food: It is important to remember that you are a guest. While you should never compromise when it comes to an issue of patient care, it’s still important to be polite and respectful. Bringing offerings of food never hurts.

Behold the transformative power of cake! Saying thank you to all my lab buddies.

Let go of your elitism: it would be really easy to leave Botswana disgusted by way some things are handled. And it’s true- there is no excuse for letting patient care fall by the wayside. It was hard to stomach sometimes: I met doctors who seemed not to care about their patients, nurses who would routinely use facebook during clinic etc etc. One time I tried to bring a very ill patient into the dermatology clinic room but the nurses insisted I find somewhere else because they wanted to go home. Patients weren’t generally handled with deference and I saw some things that really horrified me. It would be easy to emerge from this experience smug in the knowledge that many of these issue would be better handled in the US….BUT let’s remember that the US fails on patient care in other ways: we order unnecessary tests, practice defensive medicine, don’t spend enough time with our patients and we are participating in a healthcare system that is unsustainable. So coming from a place of judgment not only limits what you can learn from a place, it also is sort of hypocritical.

Going above and beyond: a nurse at Kanye

Try not to generalize: Many of the physicians I met did not take initiative at all, many would try to shunt responsibility whenever possible. In some ways, this colored my experience at the start of my trip especially because the nurses I worked with in Malawi were dedicated almost to a fault. However, for every lazy lab tech, sullen nurse and irresponsible doctor- there were 3 other people who would go above and beyond for patients, their colleagues etc. I was blown away by the microbiology lab worker who let us look at crfptococcuc under the microscope just so we could learn or Bonnie, the nurse who looked up a patient’s phone number (I still have no idea how she did that) so we could ask if they got treatment for a DVT.

Most importantly...secure the door to your room on safari: or a monkey will come in and steal your coffee...duh!

I really didn't want to leave Botswana. Like REALLY didn't want to leave. To the point where Kari and I were scheming up ways that I could change my plane ticket (turns out if I didn't fly home on the 10th the next available flight was on the 31st so that was a no go).

Byebye Bots :(

First of all, I had such an incredible summer. Second of all I was having a major case of FOMO, which is "Fear Of Missing Out." How could I leave when my flatmates were planning a camping trip? And we'd just gotten started hearing our results for pathology- how could I leave when I didn't know if firm flesh colored papules were trichilemmomas or angiofibromas?

But alas, resistance was futile and I had to say my goodbyes. My flight was in the evening but I insisted on a full day at clinic/lab. We had a celebration with the path lab people (complete with a cake we brought to say thank you for putting up with us), hugged all the nurses, checked that the VisualDx was running OK and promised everyone I'd come back as soon as possible.

My flight was uneventful and I was home in no time (and by no time I mean a full 26 hours later) Le sigh. I miss Botswana already.

The airport in Gaborone is so nice! Crazy to think that they have this nice airport but not enough beds in the hospital.

Loving that Boston pride! This is Koziba, the 2nd oldest daughter of Hilda (who is the housekeeper in the flat I stay in). She is 18, a bundle of energy and she has an adorable 1 yr old named Prince. The shirt was a gift from Ryan who is from Boston and now lives and works in Gabs (he works for Dr. Kovarik actually). Just thought I'd share the Bruins love.

Sunday, August 7, 2011

Out of office reply from Hayley G: the aforementioned blogger has spent the weekend in South Africa (again) seeing lots of cool animals (again). Upon her return she elected to eat takeout pizza and edit photos of lions instead of updating her silly little blog.

She regrets any inconvenience this may cause her adoring public (i.e her grandmother)

Cold early morning game drives merit Safari ponchos/snuggies.

Having a go at the slingshot (they use it to deter monkeys from stealing food. We could have used it when a monkey snuck into Liam's room and stole a packet of instant coffee.)

Thursday, August 4, 2011

Takes about 30 min to walk from the flat where I live to the hospital. It's actually a great start/end to the day. I usually take this opportunity to unleash a flood of derm questions that have been building up during the day.

Wednesday, August 3, 2011

Now that Doug is gone, Fresh Cafe has been put on hold (and is now probably out of business) and we've decided to explore some of the local (much cheaper) cuisine. We started with the Nurse's association which serves you a heaping plate of food for 16 pula ($2.50). We got there early because we heard that they run out of food so we met up with Panda (Liam) at 11:45. No one was there but they told us to sit down. Long story short, we finally got our food 1 hour later. Kari was basically going into hypoglycemic shock. Ah, Botswana time- how I will miss thee.

Kari's smile is hiding her desperation

The nurse's association has no sign and is on an unmarked dirt path

The next day we tried the "white house," a small restaurant-type place a block from the hospital where we payed a whooping 25 pula ($3.80) for our meals. Again, we were early (and we wonder why America has an obesity problem) and the lady who was serving the food let us sample everything. We settled on chicken, phaletshe (a maize paste just like ncima from Malawi) and begobe (a brownish porridge made from sorghum and maize. And no, I have no idea what sorghum is).

Tuesday, August 2, 2011

One of the projects I picked up while in Botswana is introducing a computer program called VisualDx (I wrote about it in an earlier post). It’s a super-impressive program with a very user-friendly interface that helps generate a differential diagnosis (list of possible diseases) for dermatology cases. It’s pretty amazing and we don’t even have it at PennMed yet (hint hint) but the creators donated a copy to Princess Marina Hospital.

Getting anything done at Princess Marina Hospital is a huge to-do and VisualDx was no exception. Finding the library, finding a working computer and getting the permission to install a program on a computer all involved numerous phone calls, text messages and visits to far-flung corners of the hospital. But anyone who knows me knows that I don't shy away from a challenge and I was determined to get this off the ground.

That gauntlet was nothing, however, compared to introducing it to the Department of Medicine. The original idea was to identify motivated residents, train them, and have them “spread the love.” I identified a few but they seemed reluctant and I was unsure if they would spread the knowledge. One of the head doctors told me to talk about it at morning report and then require all the doctors to have a training session.

Quick background- morning report is brutal. BRUTAL. Half the room is asleep and participation is literally unheard of. They once had a session assigning doctors to update certain protocols (each doctor was required to work on one section). They would read out a category and ask for volunteers and would be met with stony silence until the resident in charge assigned someone that section. This request-silence cycle went on for 20 different categories. It was painful.

Needless to say, the possibility of requiring these folks to do anything was less than desirable. Therefore, we decided instead to bring VisualDx to morning report. Kari was presenting a case (she nicely bumped the date of her presentation up to this week so I could present as well) and we incorporated VisualDx into her presentation. She talked about an ulcer that we saw on the wards and when she was done I showed how you could use VisualDx to create a differential that included the disease.

Given the apathy that characterizes morning repot, I was basically expecting crickets. I was shocked when people actually seemed to be paying attention and even seemed interested in VisualDx! Not only that but they actually signed up for an optional tutorial session! I was flabbergasted!

VisualDx tutorial

The tutorial session went really well and next step is to work on installing the program on computers in the wards (which will involve approximately 14058434 visits to the wards, the IT department, the department of medicine etc…I get a headache just thinking about it).

I have really loved being a part of this project and the wheels in my head are already turning…maybe they could use VisualDx in outreach clinics in Botswana….or maybe Uganda where my mother is helping set up an ENT residency. Maybe they need a med student to travel and install it! OK, OK, I’ll slow down and get some sleep.

Sunday, July 31, 2011

The team:, Armageddon(Kari) Kung Fu Panda(Liam, owing to the fact that he is a blackbelt in karate and captain of the Cambridge University karate team) and Bush Baby (me).

The mission: Climb Kgale hill.

As we pulled up to the car park of our confidence had already swelled: this hike won’t take more than an hour total! We started on our hike full of vim and vigor. Panda took the lead, scrambling up the rocks like a nimble tree frog (and yes, I’m aware that tree frogs don’t scramble up rocks but cut me some slack).

We made it up the totally unmarked path (which consisted of huge boulders) with only a few hiccups and were treated to some breathtaking views of Gaborone.

Why are we outside the fenced path?

Gleeful from our successful summit we started on our way back down. And this time we found a trail of green arrows! Smug, we practically skipped down the mountain and stopped to take the odd picture or two.

All was rosy and well in out world until we discovered that we were outside the fenced, concrete path we were meant to be going down. Hmmm. We were still following the green path so we continued on our merry way. Who needs a path? We were hearty Botswana trail warriors!

We continued with our green path for quite some time until we realized…approximately 1 hour later…that perchance we were veering slightly off course. How did we know? For one thing, we could barely even see the hill from which we had descended and for another, we heard the sounds of a quarry…the same quarry that we saw in the distance from the top of the hill.

And still we didn’t worry. We were following a clearly(ish) marked path. But then we came to a 3-way split in the path and none of the 3 ways seemed to be correct. OK, so now we’d lost the clearly marked path and we couldn’t see where we came from but this path had to lead somewhere, right?

But morale flagged for a brief second as the path looked less path-y and we battled copious thorn trees. We considered turning around until Panda ran ahead and shouted that he could see a road! We were overjoyed until we realized that we had wandered into a blasting zone that was basically nowhere near where we needed to be. Oops.

We wandered down the road until we came to a quarry worker (I would have loved to have been able to read his thoughts as he saw 3 white people emerge from the bush) who vaguely pointed us in the direction of game city (a mall that is a few km from the car park). Luckily, we were able to hitch a ride with a kindly gent and made it back to civilization with nothing more to show than bruised egos and a few thorn-induced flesh wounds. Maybe they will get infected with sporotrichosis and we can write up the case! (Kidding! Sort of). We ended the adventure with a giant muffin and bottomless ginger beer at Mug and Bean where we toasted to our stupidity, lack of directional sense and all-around buffoon-ery. Go team!

See that huge quarry way in the distance? Yah. We ended up on the other side of that.

Went to Fresh Cafe in the AM in honor of Dougie Fresh's last day. We saw him off and then, through the fog of our tears, Kari, Liam and I decided to deal with the lost of the Fresh-ster by going to the Gaborone Game Reserve. Our expectations were low - this "game park" is like 10 minutes from our flat and by Botswana standards, is more like a playground than Disneyworld if you will.

We needed a car to get around so we called our favorite cab driver, Tendai. Despite our low expectations we had the best time- it was awesome! We saw warthogs, ostrich, rock dassies, impala, kudu and so many monkeys. We would spot something in the distance and Tendai would gun the engine and chase it down while yelling "capture it! snatch it!" (he meant take a picture).

Toward the end of the day we came upon a cadre of monkeys who eagerly approached the car. At first I was simply charmed by the little imps but I started getting nervous as they jumped on the hood and got closer to the window. Kari and Liam were making fun of my jumpiness but I waved them off- "I'm not scared!" We drove up a bit to another group of monkeys and I had my head of the window when BAM a monkey popped up out of nowhere right near my head. I screamed and literally flung myself across the car onto Liam's lap. Keep in mind that these are vervet monkeys which are not aggressive and all of 1ft tall. Needless to say my little "episode" was the source of much amusement for my compatriots. Hmmpph.

Trying to regain composure after I launched myself at Liam. Note the monkey in the background. Cheeky lil' bugger.

Moderately less frightened. At least enough to throw the 'ol double thumbs up.

The other highlight of the game park was a small unlabled building/tent/shanty near the entrance. Intrigued, we stopped in and discovered several very dirty fish tanks with a few random fish swimming in the murk. One simply held a large, dead fish. Why was there an "aquarium" randomly in this totally dry game park? These are questions I don't trouble myself with.

Friday, July 29, 2011

One of the coolest things I get to observe is the use of the robotic microscope in the National Lab. When a skin biopsy is done (by Doug or Didi, PMH's full time dermatologist), we take it to the national lab (across the street) and Doug gives it a preliminary read (i.e. what he thinks is going on based on the microscopic appearance of the skin and the clinical data that we write down). If it's clear cut, he writes down his read and that's that. For the other cases, we load it onto the wells of the Zeiss Mirax Live RT microscope and the computer scans it. The images are sent via the internet to Carrie Kovarik in Philadelphia (who is the head of the study I am working on). She can even control the microscope remotely! She emails her reads to Doug and we write them down in the records. Simple as that.

This robotic telepathology technology is truly amazing and, at least to me, seems like the future of medicine. Especially in a developing country, it fosters a level of collaboration that would be impossible without the aid of tools like this.

If anyone is interested, there is a more in-depth article about this program (authored in part by Dr. Kovarik) in the latest issue of JAAD (the Journal of American Academy of Dermatology): May 2011 Volume 64, Number 5.